Introduction: The introduction of ex situ perfusion systems has significantly improved graft evaluation and optimization. In pediatric liver transplantation (pLT), hypothermic oxygenated perfusion (HOPE) appears to enhance graft preservation by reducing static cold storage time and mitigating ischemia-reperfusion injury. This study evaluates the use of HOPE in leading European Pediatric liver transplant programs.
Methods: A multicenter descriptive study conducted in four hospitals from 2023 to 2025. All patients under 18 years of age whose grafts received HOPE treatment were included. Data on donor and recipient characteristics, HOPE parameters, laboratory values, vascular and biliary complications, rates of primary graft failure and early allograft dysfunction, and survival outcomes were collected.
Results: A total of 56 liver transplants were performed (26 HOPE-split, 18 HOPE-reduced, 12 HOPE-whole), including 2 combined heart and liver transplantation and 5 (8.9%) from DCD donors. Biliary atresia (46.4%) was the leading indication for transplantation and 9 (16.1%) were retransplants. The graft-to-recipient weight ratio (GRWR) was 2.9±1.1. The HOPE duration was 146.2±77.1 min, reducing static cold preservation time 29%. Peak and postoperative transaminase levels (AST/ALT) on days 1, 7, and 15 were 1524/696 (IQR, 706.7–2263.2/380–1588.7), 708/574.5 (IQR, 496-1362/344.2-1238.7), 50/133 (IQR, 37-61/72.5-218.5) and 37,5/45 (IQR, 27,5-66/28-99), respectively. One case of primary graft failure (PGF) and 9 cases of mild early allograft dysfunction (EAD) were recorded. A total of 12 vascular complications (21,4%) occurred, including 5 portal vein stenoses, 5 arterial stenoses, and 2 arterial thromboses. Additionally, nine biliary complications (16%) were observed, consisting of 8 bile leaks and one biliary stenosis. All patients except 5 (8,9%) were alive with good graft function at a median follow-up of 5(IQR, 1-9) month.
Conclusions: HOPE proved to be safe in pLT, demonstrate favorable outcomes in grafts with prolonged ischemia, extensive back-table preparation or DCD donors. Further studies are needed to define its indications and evaluate its long-term impact.